Download Health Concerns of our Age

Health Concerns of our
Age-Gifted Seniors
Chris Pitsch, DO, HMDC
Objectives
 Strategies for Fall Prevention
 Diagnosing Dementia
 Addressing Polypharmacy
 Screening for Osteoporosis
 Addressing Incontinence
 Staging Pressure Ulcers
 Recognition of Common Sensory Disorders
 Define Hospice and Palliative Care
Gait Dysfunction and Falls
 According to the CDC, unintentional injuries, including falls, are now the
fourth leading cause of Death in the US
 According to the AGS, at least 20% of community dwelling older adults
admit to difficulty with walking or require assist with mobility
 Each year approximately 30% – 40% of community dwelling patients ≥ 65
experience a fall, while approximately 50% of long term care residents
experience a fall*
GRS Teaching Slides. Gait Impairment and Falls. American Geriatrics Society. (c) 2013
Question # 1
 A 76 year old female presents to your office with her family. She reports a
two week history of frequent falls, however, she denies any injury. Her past
medical history includes T2DM, HTN, and Depression. She is currently on
Metformin, Simvastatin, Aspirin, and was recently started on Lorazepam by
her psychiatrist. She is not on any anti-hypertensive. Her family is concerned
that this is a sign of Parkinson’s disease. After a thorough and normal
examination your first recommendation is:
a) Immediate Neurology consultation
b) Trial wean off of Lorazepam
c) Brain CT
d) Begin Midodrine
e) Discontinue Metformin
Gait Dysfunction and Falls
 Gait dysfunction is generally multifactorial with causes including; DJD,
Dementia, Musculoskeletal deformities, Stroke, Orthostatic hypotension,
and Fear of falling
 Medications are frequently implicated as a causative factor in falls with
common classes including; Benzodiazepines, Antipsychotics, Cardiac
meds, Hypoglycemic meds, and Antidepressants
Question # 2
 The most recent USPSTF recommendation for fall prevention in communitydwelling adults ≥ 65 who are at an increased risk for falls includes what
interventions?
a) The USPSTF found insufficient evidence to make any recommendation on
interventions in fall prevention
b) Exercise or Physical Therapy and/or Vitamin D Supplementation
c) Exercise alone
d) Physical Therapy and daily Aspirin
e) Daily Multivitamin
Gait Dysfunction and Falls
Clinical Summary: Falls Prevention in Older Adults: Counseling and Preventive Medication. USPSTF. October 2014.
uspreventiveservicestaskforce.org
Gait Dysfunction and Falls
Clinical Summary: Falls Prevention in Older Adults: Counseling and Preventive Medication. USPSTF. October 2014.
uspreventiveservicestaskforce.org
Gait Dysfunction and Falls
 Fall Prevention:
o Medication Minimization
o Vitamin D Supplementation
o Treatment of Sensory Impairment
o Environmental Modification
o Podiatric care and appropriate footwear
o Physical Therapy/Exercise Program
o Appropriate management of orthostatic hypotension and other cardiac
issues
Dementia
 Types of Dementia
 Alzheimer’s
 Vascular
 Lewy Bodies
 Frontotemporal
 Mixed
 Less Frequent Dementias: Creutzfeldt-Jakob disease, Huntington’s,
Wernicke-Korsakof syndrome, and normal pressure hydrocephalus
Dementia
 Defining Dementia
 Historically the DSM has been frequently used to define Dementia
 The most current DSM, DSM V no longer lists Dementia separately but
includes it in the broader category of Major Neurocognitive Disorders
 In order to meet criteria for a diagnosis of Major NCD a patient must show
significant cognitive decline that interferes with their independence
(ADL’s/IADL’s) and is not due to delirium or other mental disorder
 In addition to a cognitive decline patients with Dementia have at least 1 of
the following: Impaired Executive Function, Agnosia, Aphasia, and/or
Apraxia
Dementia
 Alzheimer’s
 Accounts for 50%-75% of Dementia Cases
 Insidious onset and gradual progression
 Risk Factors include advanced age and family history
 Vascular Dementia
 Accounts for 20%-30% of Dementia Cases
 Presentation depends on extent and location of cerebrovascular event
 Risk Factors Include smoking, advanced age, HTN, HLD, Diabetes, and male
sex
Dementia
 Dementia with Lewy Bodies
 Accounts for 10%-25% of Dementia Cases
 Like Alzheimer’s an insidious onset and gradual progression is typical
 Detailed, recurrent visual hallucinations present early in the disease
 Fluctuating cognition
 Severe neuroleptic sensitivity common
 Potential genetic risk factor but no family history in most cases
Dementia
 Frontotemporal Dementia
 Accounts for 10%-15% of Dementia cases
 Both a Behavioral variant and a Language variant have been identified,
however, many patients present with both types
 Up to 40% of cases are familial
 Mixed Dementia
 Presence of greater then one neuropathology
 Exact prevalence unknown
Question # 3
 A 76 year old Caucasian male presents to your office with his family. He states
that he is doing well and denies any complaints, however, his family reports that
he has progressive memory loss. Cognitive screening performed by you confirms
that the patient has had a significant cognitive decline. In order, to confirm your
suspected diagnosis of Dementia (Major Neurocognitive Disorder) what else
must be present?
a) Atrophy on neuroimaging
b) A positive RPR
c) Impact on ”independence” as indicated by an inability to perform one or more
ADL/IADL
d) Impact on “mood” with a positive GDS
e) Atrophy on neuroimaging without any localized ischemic changes and a
completely negative lab work-up
Dementia
 Diagnosing Dementia
 Complete History and Physical Exam
 Depression Assessment: GDS, PHQ-2, PHQ-9
 Brief Cognitive Screening Tests: MMSE, SLUMS, MOCA
 ADL, IADL Checklist
 Labs: CBC, CMP, RPR (if at risk), HIV (if at risk), B12, Folate, UA
 Imaging: Controversial. If appropriate non-contrast CT or MRI acceptable
Dementia
 Treatment
 Supportive care including modification of home environment for safety
 Remember to also screen for caretaker stress
 Removal of any unnecessary meds, especially anticholinergics and other
sedating meds
 Optimization of other medical conditions
 Cholinesterase inhibitors (Donepezil, Rivastigmine) indicated in mild to
moderate Alzheimer’s disease may slow decline in function, questionably
improve cognition
 N-methyl-D-aspartic acid (NMDA) antagonists (memantine, amantadine)
may provide modest benefit in patients with moderate to severe
Alzheimer’s
 Remember behavioral symptoms are best managed by
nonpharmacological means. Antipsychotics all have a black box warning
for use in patient’s with Dementia
Question # 4
 An 82 year old African American female presents to your office with her
Daughter. The patients past medical history includes Alzheimer’s, HTN, CAD,
and T2DM. She is on Donepezil, Metformin, Lisinopril, Metoprolol, Aspirin, and
Atorvastatin. The patient’s daughter reports that her mom has become
increasingly incontinent of urine. She is do for routine labs which you go
ahead and order. Her complete physical exam is unremarkable. The most
appropriate next step would be?
a) Urology referral
b) Schedule the patient for in office pessary placement
c) Start Mirabegron
d) Discuss the risk vs benefits of discontinuing Donepezil
e) Start Oxybutynin
Polypharmacy
 Review all meds with your patients including OTC meds
 Utilize Beers Criteria for Potentially Inappropriate Medication Use in Older
Adults
 Review meds for common drug-drug interactions
 Avoid Prescribing Cascades
 Eliminate all potential duplication of therapy
 Avoid complicated medication regimens
Polypharmacy
Polypharmacy
 Common Drug-Drug Interactions
Combination
Risk
ACE inhibitor + diuretic
Hypotension, hyperkalemia
ACE inhibitor + potassium
Hyperkalemia
Antiarrhythmic + diuretic
Electrolyte imbalance,
arrhythmias
Benzodiazepine +
antidepressant, antipsychotic,
or benzodiazepine
Confusion, sedation, falls
Calcium channel blocker +
diuretic or nitrate
Hypotension
Digitalis + diuretic
Arrhythmias
GRS Teaching Slides. Pharmacotherapy. American Geriatric Society (c) 2013
Polypharmacy
 Adverse drug events (ADEs) are responsible for 5% to 28% of acute geriatric
hospital admissions*
 Incidence of ADEs in hospitals: 26/1000 beds (2.6%)*
 ADEs occur in 35% of community-dwelling older adults*
 In nursing homes, $1.33 is spent on ADEs
for every $1.00 spent on medications*
*GRS Teaching Slides. Pharmacotherapy. American Geriatric Society (c) 2013
Osteoporosis
 Age-related decline in bone mass, subsequently leading to bone fragility
and increased fracture risk
 Risk Factors: Female gender, Caucasian or Asian Race, Prolonged
corticosteroid use, Tobacco use, Estrogen deficiency, Sedentary lifestyle,
and Excessive Alcohol use
 Diagnosis: Dual-energy X-ray absorptiometry (DEXA) Scan remains the most
accurate tool for diagnosis
 T-Scores compare patient’s values with normal and healthy bones of young
adults. A T score of ≤ 2.5 is considered positive for osteoporosis
 Z-Scores compare patient’s values with that of age and sex matched
controls
Osteoporosis
Clinical Summary: Osteoporosis:Screening. USPSTF. October 2014
Osteoporosis
 Treatment:
 Weight Bearing Exercise
 Smoking Cessation
 Diet including calcium, protein, and vitamin D
 Bisphosphonates (Alendronate, Risedronate)-1st line
 Selective Estrogen Receptor Modulators (Raloxifene)- Less effective than
bisphosphonates
 PTH (Teriparatide)- Good for high risk patients who have failed other
treatments
 Calcitonin- 2nd line therapy only
Incontinence
 Urge Incontinence- Due to detrusor over activity. This is the most common
type of incontinence in age-gifted patients
 A bladder diary can be helpful in determining the severity of the problem
 Consider UA with C&S to rule out a UTI
 Consider checking a PSA in men
 If a post void residual is greater than 200ml further work-up recommended
for urinary retention
 Treatment: Scheduled Voiding, Behavior modification, Neuromodulation,
Anticholinergic medications (Review potential adverse effects)
Incontinence
 Stress Incontinence- loss of urine during coughing, sneezung, laughing, etc.
 More common in women
 Often associated with pelvic prolapse or post surgical trauma
 Kegel exercises and pessaries may help
 Surgery offers the highest cure rate
Incontinence
 Overflow Incontinence- due to underactive bladder and/or outlet
obstruction
 2nd most common cause of incontinence in age gifted men
 Review medications including anticholinergics and calcium channel
blockers
 Consider UA and cytology
 Consider checking PSA
 Consider Urodynamic testing
 Treatment: If possible DC meds that can cause urinary retention, Consider
trial of alpha blocker or 5-alpha reductase inhibitor
 Catheterization may be necessary
Question # 5
 A 92 year old female is evaluated by you in the nursing home. You note an
ulcer on her right heal consisting of central eschar with surrounding
erythematous border. The wound diameter is 4.4 cm’s but you are unable
to determine depth secondary to eschar. You correctly stage this pressure
ulcer as?
a) Stage 1
b) Stage 2
c) Stage 3
d) Stage 4
e) Unstageable
Pressure Ulcers
 Secondary to prolonged pressure frequently in the setting of poor nutrition,
poor circulation, and decreased subcutaneous tissue
 Prevention is Primary
 Stage 1: Nonblanchable erythema of intact skin
 Stage 2: Partial-thickness superficial skin loss up to subcutaneous tissue
 Stage 3: Full-thickness skin loss through subcutaneous tissue
 Stage 4: Tissue loss down to the level of muscle, tendon, or bone
 Unstageable: Full-thickness tissue loss with inability to determine the depth
of the wound secondary to covering by slough and or eschar
Sensory Disorders
 Visual Impairment: Prevalence increases with age. Affects 20%-30% of those
75+ with the prevalence of blindness at 2% in the same age group*
 50% of the blind population is 65 or over*
 Cataracts:
 Symptoms include increased glare, decreased overall visual acuity and
decreased contrast sensitivity
 Risk factors include increased age, diabetes, smoking, and increased UV
light exposure
 Treatment is surgical extraction
*GRS Teaching Slides. Vision Impairment. American Geriatrics Society (C) 2013
Sensory Disorders
 Age-related Macular Degeneration:
 Most common cause of irreversible blindness in age gifted patients
 Dry form: Presence of drusen
 Wet form: choroidal neovascularization
 Treatment: Vitamin C, vitamin E, zinc, β-carotene. Intravitreal injections of vascular
endothelial growth factor inhibitors and laser surgery
Sensory Disorders
 Glaucoma:
 Defined as characteristic optic nerve head damage and visual field loss
 Affects >2.25 million Americans >40 years old. Second most common cause
of irreversible blindness worldwide; most common cause among African
Americans*
 Open-Angle Glaucoma-most common form, causes are multifactorial.
Elevated intraocular pressure is a major risk factor
 Acute Angle-Closure Glaucoma-Redness and pain with acute vision loss,
often associated with nausea and vomiting. Emergent Ophthalmology
referral
 Treatment: Intraocular pressure lowering medications, Laser
trabeculoplasty, drainage devices
*GRS Teaching Slides. Vision Impairment. American Geriatrics Society (C) 2013
Sensory Disorders
 Hearing Impairment:
 Prevalence increases with age
 Anywhere from 50%-100% of nursing home residents have some degree of
hearing impairement*
 Conductive hearing loss: Can be caused by cerumen, foreign body, or
middle ear pathology
 Sensorineural hearing loss: most often from age, noise damage (causing
cochlear disease), or ototoxicity
GRS Teaching Slides. Hearing Impairement. American Geriatrics Society (c) 2013
Hospice and Palliative Care
 Palliative Care focuses on relief of distressing symptoms including pain,
nausea, vomiting, dyspnea, and others
 Initiation of Palliative care is appropriate at anytime in the course of a
serious illness. It is not limited to end of life
 Initiation of Palliative care at the onset of a serious illness, especially cancer,
is becoming more common place
 Hospice is the gold standard of palliative care
 Hospice is a Medicare benefit, but requires the physician to certify that the
patient’s life expectancy (if their disease process was to follow the
expected course) is 6 months or less
Answer Key
1. B
2. B
3. C
4. D
5. E
References

Ward, Katherine T and Reuben, David B. Comprehensive Geriatric Assesment. Jan 21,2016. Uptodate.com
https://www.uptodate.com/contents/comprehensive-geriatricassessment?source=search_result&search=geriatric+assessment&selectedTitle=1%7E64

Le, Tao; Mendoza, Michael; Coffa, Diana (2012-07-20). First Aid for the Family Medicine Boards, Second Edition (FIRST AID
Specialty Boards) McGraw-Hill. Kindle Edition.

Clinical Summary: Falls Prevention in Older Adults: Counseling and Preventive Medication. USPSTF. October 2014.
http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/falls-prevention-in-older-adultscounseling-and-preventive-medication

Rochon, Paula A. Drug Prescribing for Older Adults. May 23, 2016. Uptodate.com
https://www.uptodate.com/contents/drug-prescribing-forolderadults?source=search_result&search=geriatric+prescribing&selectedTitle=1%7E150

Clinical Summary: Osteoporosis: Screening. U.S. Preventive Services Task Force. October 2014.
http://www.uspreventiveservicestaskforce.org/Page/Document/ClinicalSummaryFinal/osteoporosis-screening

GRS Teaching Slides. Gait Impairment and Falls. American Geriatrics Society © 2013.

GRS Teaching Slides. Dementia. American Geriatrics Society © 2013.

In brief for healthcare professional. Issue 7. Differentiating Dementias. Alzheimer’s Association © 2016.
https://www.alz.org/health-care-professionals/documents/InBrief_Issue7dd_Final.pdf

GRS Teaching Slides. Visual Impairement. American Geriatrics Society © 2013.

GRS Teaching Slides. Hearing Impairment. American Geriatrics Society © 2013.

Ham, Richard J.; Sloane, Philip D.; Warshaw, Gregg A.; Potter, Jane F.; Flaherty, Ellen (2014-01-02). Ham's Primary Care
Geriatrics: A Case-Based Approach (Ham, Primary Care Geriatrics). Elsevier Health Sciences. Kindle Edition.